The advantages of arthroscopic surgery are significant, however, the procedure has been technically demanding, particularly with respect to rotator cuff repair. The introduction of second-generation anchors with improved holding power and larger eyes which allow sutures to slide easily through them, and clear cannulas which improve visualization, have made the procedure easier. Until recently, however, passing suture through the cuff has been a challenging, multi-step process beyond the skill (or patience level) of many surgeons. This is especially true for surgeons who only infrequently do rotator cuff repairs.
In 2001 in the state of New York, 9,207 cuff repairs were performed by 859 surgeons. During this time period, 90 percent of the New York doctors who performed rotator cuff repairs performed 24 or fewer cuff repairs each, an average of less than one every two weeks. The infrequency with which these doctors perform the procedure generally prevents them from developing the skills necessary to perform the procedure arthroscopically. The recent introduction to the market of instruments which are able to pass braided suture without the use of a shuttle (a device which is first passed through the cuff, and is then used to pull the suture through the cuff) has removed much of the difficulty. The ExpresSew™ by Surgical Solutions, LLC (Valencia, Calif.) is able to directly pass braided suture through a cuff. The Needle Punch™ by Arthrex Incorporated (Naples, Fla.) is able to grasp the cuff, pass braided suture through the cuff, and bring the suture out through the cannula used for access (the working cannula).
While the problem of passing a suture through a cuff arthroscopically has been largely eliminated, suture management has become critical to the technical success of the surgery. Indeed, tangled sutures can terminate an arthroscopic procedure. This problem is compounded by the fact that many anchors now are loaded with two sutures so as to create two vertical stitches which can be slightly separated so as to distribute the load over a greater area of the tendon. This improves the strength of the repair, but at the same time gives the surgeon four suture “legs” with which to deal.
Arthroscopic rotator cuff repairs are performed in a space which is filled with pressurized liquid, generally normal saline, the surgeon working through various small incisions or portals. Pressurization of the joint and leakage of liquid from the joint is controlled by cannulae which are inserted into the portals, the cannulae having seals through which instruments and sutures may be passed.
Common suture management techniques call for removal of sutures from the working cannula in order to avoid tangles. The sutures are then retrieved one at a time as needed. Some advocate making extra punctures for the sole purpose of temporarily storing sutures to avoid tangles. Others recommend retrieving one suture through the mid-glenoid working cannula, and retrieving the other limbs through the anterior superior cannula, after which the cannula is removed and reinserted leaving the sutures through the portal outside the cannula. Transporting sutures from one cannula to another or to alternative portals can occupy large blocks of time during a given operation. Also, removing and reinserting a cannula may increase trauma to local tissues. There is a need for a more efficient suture management system, minimizing the multiple extra steps inherent in the currently recommended techniques and their associated increased trauma.
Performing an arthroscopic rotator cuff repair is a multi-step process. The bone bed is prepared using a high-speed buf, adjacent to the articular surface of the humeral head. Anchors are placed in the bone bed, each anchor generally loaded with two strands of suture so that four tails are created. One leg of each suture is passed through the cuff, suitably spaced so as to distribute the load over a greater area of the tendon. One set of sutures is pulled laterally as traction sutures to retain tension and position of the cuff during suture knot tying of the second set of sutures. Traction suture tension is generally maintained by an assistant holding onto the suture legs which pass from the working cannula. The traction sutures are tied after the first set of sutures. The process of applying traction and tying suture pairs is repeated until all sutures are tied. There is currently no method for applying tension to a traction suture which does not require an assistant to hold the suture.
The use of a traction suture also frequently leads to excessive leaking and spraying from the working cannula since the suture under tension often distorts the seal through which the suture passes thereby allowing the flow of liquid.
It is, accordingly, an object of this invention to produce a method for suture management which prevents tangling of sutures and allows tensioning of a traction suture without manual assistance.
It is also an object of this invention to produce a method for tensioning a traction suture while minimizing fluid leakage from the joint.
It is also an object of this invention to produce a method for tensioning a traction suture while maintaining fluid pressure within the joint.
It is also an object of this invention to produce a method for suture management which prevents tangling of sutures but does not require transporting of sutures from the working cannula to avoid tangles.
It is also an object of this invention to produce a method for suture management which prevents tangling of sutures and thereby reduces procedure time and complexity.
It is, accordingly, an object of this invention to produce a device for suture management which prevents tangling of sutures and allows tensioning of a traction suture without manual assistance.
It is also an object of this invention to produce a device for tensioning a traction suture while minimizing fluid leakage from the joint.
It is also an object of this invention to produce a device for tensioning a traction suture while maintaining fluid pressure within the joint.
It is also an object of this invention to produce a device for suture management which prevents tangling of sutures but does not require transporting of sutures from the working cannula to avoid tangles.
It is also an object of this invention to produce a device for suture management which prevents tangling of sutures and thereby reduces procedure time and complexity.
It is yet a further object of this invention to produce a device for suture management which minimizes or prevents outward spraying during use.